Overhead Squat Assessment: Introduction
Tuesday, June 6, 2023 - 205 Likes
Brent Brookbush
DPT, PT, COMT, MS,
Introduction to the Overhead Squat Assessment
by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, H/FS
OHSA with Modification (Heel Rise)
Definition:
Overhead Squat Assessment (OHSA) - A dynamic/transitional posture assessment that combines end-range shoulder flexion with a squat (sit-to-stand transfer).
Why the OHSA (Relevance)? This assessment is designed to highlight deviations from ideal motion with the intent of informing intervention selection. Dynamic/transitional postural assessments are particularly well suited for highlighting altered movement patterns that may incorporate multiple body segments, joints, muscles, fascia and/or neural structures. That is, this category differs from most assessments which attempt to identify a single structure or joint motion that may be contributing to the patient/client's complaints. For example, although a manual muscle test for the gluteus medius may indicate gluteus medius weakness.; the OHSA may imply that this weakness is a contributing factor of a lower extremity compensation pattern that includes additional structures crossing the hip , knee and ankle - as is often the case when an individual exhibits the sign Knees Bow In (discussed in greater detail below).
- What the OHSA is Not: The overhead squat assessment is not a diagnostic test. The overhead squat is not designed to be a valid measure of joint or muscle pathology, is not designed with the intent of aiding in differential diagnosis, and should not be used as a "catch-all" assessment that replaces all other assessments. The Brookbush Institute recommends that the OHSA is one assessment used in a group of assessment that may also include a subjective examination, special/orthopedic tests, goniometry , muscle length tests , and manual muscle testing , provided the testing falls within the human movement professional's scope-of-practice. The OHSA is one of many tools in our evaluation/assessment tool box. Unlike special tests (e.g. Lachman test, Hawkins/Kennedy , or the Canadian C Spine Rules, etc.) that are used to diagnose/determine the likelihood of pathology, the OHSA is an assessment designed to assist in the development of a routine (sequence of exercises and interventions) to enhance the quality of human movement. If the results from a subjective evaluation, and/or special tests, imply that a physician or imaging may be required to confirm or reject the possibility of joint, muscle, fascial or nerve pathology, the OHSA may be contraindicated.
Printable PDF of Movement Assessment Template: Movement Assessment
A Peak into the Minds of Giants - "The primary basis of the functional approach to musculoskeletal (orthopedic) pain syndromes is the interdependence of all structures…" - Vladimir Janda (3). The concept that pain and postural dysfunction may be correlated seems to have been adopted following publications by Kendall and Janda in the 1950s - 60's (1-3); a relationship that is know supported by dozens if not hundreds of studies (see "Validity and Reliability" below). The term "interdependence" has evolved, and is now often referred to as "regional interdependence", a concept coined by Wainer et al. in the early 2000's (12, 13), and again supported by dozens of studies (See "Regional Interdependence" below)
Similar in nature to a static posture assessment (e.g. Plumb Line Assessment), the OHSA is designed to highlight deviations from a model of ideal motion, and/or ideal alignment of bones and joints. The OHSA could be viewed as a progression of the Plumb Line Assessment in that it is dynamic, functional (related to: sit-to-stand transfer, squatting and jumping) and likely more provocative. The provocative nature of this assessment allows for the construction of a reliable protocol and set of signs; that is, compensation patterns that are barely perceptible during a static posture assessment, are consistently and easily identified during the OHSA.
Dr. Brent Brookbush instructing a class on potential issues with set-up of the OHSA
Building a Model of Ideal Motion:
Defining “Posture”:
I believe the loose definition of this term has lead to significant confusion, unwarranted critique of a postural dysfunction/movement impairment model, as well as, questions regarding the validity of the OHSA. Occasionally I find articles dismissing the idea of “posture” as a contributor to pathology and impaired performance, only to find the conclusion of their article a sound solution to correcting the very thing they dismiss. The Brookbush Institute's definition of posture:
Posture –
“Ideal Posture” – Ideal arthro- and osteo-kinematics maintained by optimal myofascial activity and length, as a result of accurate sensation, integration and activation by the nervous system – both statically and dynamically.
By Corollary: “Postural Dysfunction” is the absence of ideal posture as a result of maladaptation by one or multiple tissues within the human movement system.
Ideal Alignment (Kinetic Chain Checkpoints) during an Overhead Squat Assessment:
In most cases, the results of an assessment are compared to normative data. In some assessments, including the OHSA, the results are compared to a set of "normative data" used to construct an "ideal model." All assessments are designed to define, compare, or illustrate differences between a normal set and an abnormal set. The OHSA compares an "ideal model" to a set of known "movement impairments/postural dysfunctions." Movement impairments/postural dysfunctions have been previously described by Janda, Sahrmann, Chaitow, Leigenson, and Clark et al. (1-4, 9, 10). "The Ideal Model" (i.e. Set of Norms):
- Feet: Hip width (2nd toe directly below the ASIS, i.e. hip joint width), feet are parallel to one another (2nd toe pointing forward), the medial longitudinal arch of the foot is maintained.
- Room for debate: Based on available research on the ankle , a less "strict" ideal may exist; however, this is likely influenced by the population treated, professional's scope, and repertoire of interventions. Foot position is commonly cued as hip to shoulder width (slightly wider than hips), and feet parallel may refer to the first or second ray parallel (big toe, or second toe). Often, professionals will allow a significant amount of "turn out" during a squat, and defend the foot position, by quoting that "15° of foot/ankle external rotation is normal." Howver, this is the malleolar angle without consideration of additional bone joint angles of the lower extremity, and does not account for the 25-45° seen practiced by some. 15° of foot/ankle "turn out" using the center of the foot as a starting position would only be enough "turn-out" to result in 1st ray pointing forward. Clinically, the stricter guidelines described above have proven more provocative/sensitive, and therefore, have resulted in more consistent and positive outcomes.
- Knees: Underneath hips, knee caps face forward, patella tracks over second and third ray (toes).
- Pelvis: Normal lumbar curve, neutral pelvis (anterior superior iliac spine (ASIS) within an inch of level of the posterior superior iliac spine (PSIS)), no right to left asymmetry.
- During the OHSA, from a lateral view, a line between the ASIS and PSIS, and the mid-axillary line should remain nearly 90º.
- Tibia and Torso: The tibia and the mid-axillary line should remain parallel to one another throughout the OHSA.
- Shoulder Girdle: Shoulder blades down and back (upward rotation and posterior tipping without excessive elevation)
- Arms: Arms remain inline with torso with elbows locked, maintaining roughly 180º of flexion and 150º to 170º of abduction.
Set-up and Optimal Posture
Set Up Instructions:
- Do your best not to indicate the objective of the assessment, or what signs you are looking for during the assessment. We do not want clients/patients attempting to assume "ideal posture" and altering the results of the OHSA.
- Ask your patient/client to stand with feet hip width apart.
- Because foot placement may be a bit random, and an individual may assume a range of comfortable foot positions, cue and manually adjust foot position so that the OHSA is started with ideal foot position (or as close a foot position as can be achieved).
- Ask your patient/client to reach "straight up" over their head with elbows "locked".
- Ask your patient to "sit down" and "stand up" as many times as necessary to assess if the signs discussed below are present.
- Helpful Tips: For those who do not know how to squat or may be a falls risk, this can be done with a chair, and thought of as a "sit-to-stand transfer assessment".
- For advanced exercises and athletes who may "know what a squat should look like", it may be helpful to have them close their eyes, reducing visual input and their ability to self-correct.
- Common Mistakes:
- Stick to the "Signs": It is tempting to start noting every "deviation" based on a personal frame-of-reference of squat form. The only signs that have been correlated with dysfunction and successful intervention are the signs discussed below. Adding additional signs to the assessment, however well intentioned, may serve to invalidate the assessment, and/or reduce reliability.
- Helpful Tips: For those who do not know how to squat or may be a falls risk, this can be done with a chair, and thought of as a "sit-to-stand transfer assessment".
Common Signs of Dysfunction:
It is important to stick closely to the signs of dysfunction listed above for several reasons.
- Inter- and intra-tester reliability is dependent on a consistent observations by all assessors, every-time the assessment is used.
- Some observations may correlate poorly with dysfunction, or intervention selection.
- Do not look for observations that cannot be explained by your current knowledge base.
- The signs below are based on evidence from 3rd party research and outcomes.
Although discovery and innovation are always welcomed, the scientific method should be considered. At the very least, any new sign should be added following with a defined ideal and deviation, a review of relevant research, should then be assessed in every individual, a corrective intervention should be hypothesized and tested on those individuals exhibiting dysfunction, and if clinical outcomes appear to show validity, an attempt should be made to initiate 3rd party research.
Signs of Dysfunction:
Analyzing Signs and Patterns
Each visually observable sign is correlated with a joint action(s), for example Feet Flatten = Ankle Eversion
- A Note on Observation: No one can see muscle activity or length, but everyone can see motion, i.e. joint actions. Joint actions can then be used to infer muscle length and activity, and potentially the behavior of other structures (joint, fascia, nerves) Example, you cannot see "tight hip flexors," but you can see excessive hip flexion.
Understanding movement impairment starts with analyzing the most commonly seen compensatory pattern for each body segment. We start by examining altered joint position and the effect that has on relative muscle length:
- Know what good posture looks like ("Ideal Model" versus "Common Signs").
- Identify the excessive joint action that correlates to the sign of dysfunction
- List muscles responsible for that joint action ("short" muscles).
- Identify the opposing joint action.
- List the muscles responsible for the opposing joint action ("long" muscles).
It is important to create an organized method of determining which muscles are long, and which are short (e.g. the table below). Initially, it may be necessary to review functional anatomy when building these tables. Repetition will lead to memorization of the muscles responsible for each joint action, quicker assessment, and given enough time and practice, you may notice patterns. These patterns will look very similar to the predictive models of postural dysfunction discussed in the articles - Postural Dysfunction/Movement Impairment .
Observed Joint Action(s) | Short Muscles | Opposing Joint Action(s) | Long Muscles |
Generally, muscles associated with the observed joint action are short and overactive, and the opposing muscles are long and under-active. Initially we can use these tables to build corrective intervention using the National Academy of Sports Medicine – Corrective Exercise Training Model (10).
- * Release over-active muscles
- Stretch short muscles
- Activate under-active muscles
- Integrate long muscles
A more comprehensive, and perhaps more accurate analysis can be constructed using additional resources; however, this also adds to the complexity of analysis and intervention. The Brookbush Institute has continued to refine analysis through years of testing in an outcome driven practice, and consideration of all 3rd party research that can be acquired. It is our suggestion that you enhance your understanding by reading the following in the order recommended
- Analysis of Signs and Patterns:
- Postural Dysfunction/Movement Impairment
- Individual Research Studies (Many of these are summarized below under "Validity and Reliability")
5 Steps for Analyzing Dysfunction:
How to use the OHSA:
The Brookbush Institute uses the OHSA as a "top tier" assessment. That is, after a subjective assessment and special tests (if necessary) are performed, the OHSA is the first movement assessment, dictating the pattern that will be addressed and which additional movement assessment will follow. Generally, the OHSA serves 3 functions:
- Identify the Dysfunctional "Segment": Example, a patient/client complains of "low back pain" and exhibits an Excessive Forward Lean on the OHSA; further assessment is used to identify whether ankle and/or hip dysfunction are contributing to the patient complaints.
- Identify Patterns of Compensation - Example, a patient/client feels weak during push-off, and a prior assessment by a medical professional noted a decrease in hip internal rotation range of motion. During and OHSA you note that this may be part of a compensation pattern, as the patient exhibits the sign "Knees Bow Out ".
- Develop a priority list and/or sequence for intervention - Example, a college athlete continues to get side-lined by nagging left ankle, right knee, right hip, low back and neck pain. Although none of these issues seem worthy of "going to the doctor", the student complains that he cannot seem to recover quick enough to "practice hard". During the OHSA, you note the individual exhibits an asymmetrical weight shift , excessive forward lean , and arms fall . You start with the asymmetrical weight shift based on the filter below.
Prioritizing Multiple Dysfunctions:
- Obstructive Dysfunction - The sign preventing the individual from performing ADL's.
- Asymmetrical Dysfunction - Right to left asymmetry.
- Worst Dysfunction - Most often this is hard to determine, but occasionally a patient/client will present with an obvious "worst".
- Bottom Up - If presented with multiple, bilateral dysfunctions, it is generally best-practice to work from the foot/ankle complex and progress up the kinetic chain.
**Validity and Reliability:
**
Good tests, assessments and evaluations are relevant, valid and reliable -
Validity - The OHSA is used to identify deviations from an ideal norm that may result from changes in myofascial activity and length, altered osteokinematic and arthrokinematic motion and/or abnormal motor control. Ideally, these deviations would aid in predicting the best possible strategy for correcting impairment. This assessment has evolved from the conceptual frameworks of postural dysfunction, movement impairment and motor control, and the work of such great minds as Kendall, Janda, Lewit, Sahrman, Richardson et al., Leibenson et al., Vleeming et al., Clark et al., etc. (1-10). Although research that examines the OHSA specifically is limited, if the assessment is viewed as a cluster of commonly observed signs, their is sufficient evidence to support its validity and use. Most importantly, the Brookbush Institute urges 3rd party research institutions to consider this assessment as a focus for validity and reliability studies in the future.
- Feet Flatten - Feet flatten has been correlated with tibialis posterior dysfunction (14-18), and selective activation/exercise for the tibialis posterior has been shown to have a positive effect on foot/ankle and lower extremity kinematics (19-20). Although these studies did not use the OHSA as an outcome measure, description of the sign"eversion/pronation" in these studies is similar to the description of the sign "feet flatten" used for the OHSA. Most of these studies referred to the "Navicular Drop Test", which may be used as an objective interval measure in conjunction with the OHSA to monitor progress. In a study by Trimble et al. this sign, assessed with a lower extremity posture test was found to be a better indicator of tibial translation than recurvatum or thigh foot angle (84).
- Feet Turn Out - Only two studies have correlated feet turn-out with dysfunction. In a study by Winslow et al., feet turn out was correlated with a positive "Ober's Test " (tensor fascia latae restriction/over-active) and knee pain (21), and in a study by Andrew et al., feet turn out was correlated with a functional varus and linked to knee osteoarthritis (40). However, other studies have shown a correlation between an increase in biceps femoris activity (a strong tibial external rotator) and knee dysfunction/pain (22, 23). In an interesting study by Hasegawa et al., biceps femoris stretching resulted in a relative increase in vastus medialis activity (23); this may be evidence that conservative treatment (exercise/manual therapy) may improve this impairment. It is worth noting, tibial external rotation may also be a component of "Knees Bow In" (functional valgus), as femoral internal rotation can be viewed as relative tibial external rotation.
- Knees Bow In (functional valgus) - Research has correlated a functional valgus with a decrease in gluteus maximus and medius activity, sacroiliac joint dysfunction, excessive hip internal rotation and adduction, a loss of dorsiflexion, and excessive pronation (20, 24-33, 87-88). Studies have also correlated this sign of dysfunction with increased risk of anterior cruciate ligament (ACL) injury and patello-femoral pain (ACL) (24, 27, 28). Several studies have also noted the effectiveness of specific exercise intervention for correcting this dysfunction (20, 35-36). Although the OHSA is not used by name in any of these studies, in many of them, a squat or depth jump (LESS test) was used as to assess to measure the presence as knees bow in (referred to this sign as a "functional valgus" or "medial knee displacement") (20, 24, 28 - 34)
- Knees Bow Out (functional varus) - In a study by Noda et al., this sign correlated with reduced ankle dorsiflexion and hip internal rotation using goniometric assessment (86). Further, there are several studies showing a correlation between functional varus (measured via gait or imaging) and knee osteoarthritis (37-39). Further, one study correlated an increase in varus loads on the knee with increased feet turn out and feet flatten during gait (40). One study showed that gait retraining (a conservative, exercise based approach) was effective for reducing a functional varus (41).
- Anterior Pelvic Tilt (excessive lordosis) - This is an interesting sign relative to available research. Although it is not possible to find a single study that correlates all factors related to this sign, for example - an increase in lumbar lordosis, with a loss of hip range of motion, with an anterior pelvic tilt, with altered motor control and low back pain - there are numerous studies that correlate 2 or more of these signs/symptoms (42-50). The strongest correlations likely exist between an anterior pelvic tilt, low back pain and a loss of hip extension and internal rotation, and a relative reduction in transverse abdominis , multifidus , gluteus medius and gluteus maximus activity (42 - 50, 82). In one study by Cholewicki et al., a correlation was made between altered motor control and future low back pain (42); a rare study that implies dysfunction precedes pain! Several studies have shown that exercise is effective in the treatment of low back pain (and presumably an anterior pelvic tilt) (51-55), especially long-term (55).
- Excessive Forward Lean - Two studies have shown a relationship between dorsiflexion restriction and excessive trunk flexion during squatting (and additional changes in kinematics) (32, 56). Two additional studies have demonstrated a decrease in gluteus maximus strength and activity related to ankle dysfunction (34, 57), which may partially explain the inability to maintain upright posture. Clinically, addressing dorsiflexion range of motion and addressing gluteus medius and gluteus maximus activity and strength have consistently resulted in positive outcomes.
- Arms Fall - Although this sign would seem to indicate over-activity (or a loss of extensibility) of shoulder extensors, it is important that analysis of this sign considers extensors only from 180° of shoulder flexion, as performed during the OHSA. With some analysis and review of anatomy, the list of muscles generated could be summarized as "all shoulder internal rotators and the "posterior deltoid ". This list of muscles, has the added benefit of agreement with various texts that note "excessive internal rotation" in static posture in those exhibiting upper body postural dysfunctions (1-4, 9-10). Research has confirmed a portion of this list, as an increase in subscapularis and posterior deltoid activity has been observed in those experiencing shoulder pain (58, 59). However, there may be any easier method of validating this sign on the OHSA. "Arms fall" is nothing more than an inability to maintain 180° of shoulder flexion, and shoulder flexion goniometry has been shown to be a very reliable assessment (60-64). Although the OHSA may not be a good measure of progress due to the binary nature of assessment results; shoulder flexion goniometry may be used in conjunction with the OHSA as an objective interval measure to monitor progress. There is a gap in the research regarding this sign. There is no single study that correlates the sign "Arms Fall" with common shoulder pathologies (like shoulder impingement syndrome (SIS)), and further, no study that correlates how specific interventions may improve the sign "Arms Fall". However, pain during end range shoulder flexion (as performed in the OHSA) is perhaps the most common complaint among those exhibiting symptoms of SIS, and there is a significant amount of research on external rotator activation (a commonly used intervention to treat SIS), and various studies have demonstrated that exercise is effective for the treatment of SIS (70 - 72).
- Scapula Elevate - This sign, like the sign above (Arms Fall ), must be considered relative to functional anatomy. Although it may be presumed that "elevation" of the scapula is observed, closer examination will reveal this motion is actually elevation of the superior angle of the scapula around a relatively fixed glenoid fossa, in conjunction with sagittal plane motion of the scapula over the top portion of the rib cage. The resulting excessive joint actions are relative downward rotation and anterior tipping of the scapula. Once this discrepancy between observation and analysis is solved for, this sign is presumably valid based on agreement with research relative to shoulder dysfunction. Research by Lawrence et al. , demonstrated relative downward rotation and an increase in anterior tipping of the scapula in those with shoulder pain (65). Further, research by Scavozzo et al found that swimmers with symptoms of shoulder impingement exhibited less than half the normal activity of the serratus anterior (an upward rotator and posterior tipper of the scapula) during the pull-through phase of stroke (58). An indirect relationship may also exist between this sign and a thoracic kyphosis, as a thoracic kyphosis has been correlated with shoulder impingement syndrome (66), and shoulder impingement syndrome with scapular dyskinesis (58, 65, 67 - 69). There is a significant amount of research to refine and support the use of scapular mobility techniques , serratus anterior activation and trapezius activation , and as mentioned above, exercise has been shown to be effective for the treatment of SIS (70 - 72).
Validity, Patterns of Compensation and Regional Interdependence
Dynamic/transitional posture assessments like the OHSA have the advantage of being capable of highlighting patterns of compensation that span several joints, and these patterns may be analyzed to implicate multiple myofascial, neural and articular structures. The concept that a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s) is referred to as regional interdependence (12-13). Various studies highlight this concept, increasing the validity of this presumed advantage of the OHSA. Here are a few evidence-based examples of regional interdependence, most from the references above:
- Several studies have noted a relationship between the ankle and hip , including a correlation between decreased gluteus medius and gluteus maximus activity and ankle dysfunction (32-34, 73, 83).
- Nearly all studies related to "functional valgus" correlate knee dysfunction with changes in ankle and/or hip joint motion (24-34, 83, 87-88).
- Dysfunction of the elbow and forearm may alter scapular muscle activity and endurance (74, 75).
- Forward head posture and cervical dysfunction may alter muscle activity and motion of the scapula (76-78)
- Pain and dysfunction of the sacroiliac joint (SIJ) or lumbar spine may alter the activity of any or all muscles of the trunk and hip (42 - 50, 82)
- Several studies have have indicated a relationship between scapular dyskinesis and shoulder dysfunction (58, 65, 67-69)
- Admittedly, the last two examples are not particularly distal relationships; however, it is still worth consideration and additional thought, as it implies that the serratus anterior may be contributing to shoulder impingement syndrome, or that right sided lumbar pathology may reduce left gluteus medius activity.
Reliability - Research concerning the reliability of the OHSA is incomplete. The lower extremity signs appear to have good to great, inter- and intra-tester reliability; however, there is no research related to the reliability of the upper body signs and no similar tests to compare them to. Overall, the assessment appears to be based on a strong theoretical framework, and the initial research is very promising for this relatively "new" assessment.
- Direct Evidence: Initial research on the intra- and inter-tester reliability of the OHSA has been shown to be good to excellent in various studies; however, these studies have only examined the reliability of lower body signs (24, 80, 81, 83 - 87). Three points that may be noteworthy, were the reliability in identifying a pattern associated with higher risk of ACL injuries (24), correlation between pronation and tibial translation (84), and two studies demonstrating a relationship between the overhead squat assessment and restrictions noted via goniometry (86, 87)
- Indirect Evidence: The number of studies from various researchers using the squat as an assessment to indicate the presence of a functional valgus, with many of those studies producing over-lapping, similar or congruent outcomes, may be indirect evidence of the high reliability of the OHSA (24, 28, 31, 32, 80, 81, 84 - 88)
- Need for Further Research: Research needs to be done to determine the reliability of the lumbo-pelvic hip complex and upper body signs (Excessive Forward Lean , Anterior Pelvic Tilt , Arms Fall , Scapula Elevate )
For analysis and recommended corrective exercises:
- Overhead Squat Assessment: Signs of Dysfunction
- Overhead Squat Assessment: Sign Clusters and Compensation Patterns
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- Exercise Helps Functional Valgus
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- Anterior Pelvic Tilt
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- Exercise Low Back Pain
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- Excessive Forward Lean
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- As well as studies 32 and 34
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- Shoulders Elevate
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- and 58
- Regional Interdependence
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- **Reliability and additional research **
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(C) 2017 Brent Brookbush
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